You would be forgiven for thinking that waiting times had reduced. You would be… possibly right, possibly wrong. The correct answer is that we don’t know. Performance against the weekly A&E waiting time targets—which is what all of the above are actually reporting—tells us nothing about the waiting time in A&E.

As an aside, before we get into this properly, I should clarify that “waiting time” doesn’t mean what most people think it means. The “waiting time” referred to in these statistics is the total time a patient spends in A&E, from the moment they walk in the door, to the moment they walk out again (whether that is to go home, to go to a ward, to go to the pub, or wherever). That’s not what we think of as “waiting” in common parlance: while you’re with the doctor, you are—in statistical terms—still “waiting”.

The NHS doesn’t report on waiting times, only on the proportion of patients seen in less than four hours. When the reporters wrongly say that A&E waiting times have improved, what they actually mean is that a greater proportion of people entering A&E are leaving again in less than four hours. This tells nothing about the amount of time people wait on average.

Imagine an A&E department that sees only five patients: A and B have minor injuries, and are seen and treated within 30 minutes. C and D need a more complex set of investigations, so end up being in the A&E department for 3 hours. E needs a very full assessment and ultimately admission; as a result, E ends up being in the department for a total of 5 hours before a bed can be found. The average time these patients spend in A&E is 2 hours and 24 minutes; 80% of them were discharged in 4 hours.

Now let’s say that someone puts a laser-focus on that 80% and says it’s unacceptable: whatever the cost, it must be brought down. So the department tells the nurse that used to do the “see and treat” job (which served patients A and B so well) that she must help with only the most complex patients, because they are breaching the target.

The same five people with the same five injuries now come into the revamped A&E. A and B have minor injuries, but now must wait alongside everyone else. They hang around for 3 hours. C and D need complex investigations, but these are slower to start because of people with minor injuries clogging up the queue. They are discharged after 4 hours. The new complex patient team deals with patient E slightly faster, getting her up to the ward with seconds to spare before the four-hour deadline.

100% of patients were seen within 4 hours. The hospital’s management is overjoyed! The BBC tweets that A&E waiting times have decreased: 100% of patients are seen within four hours instead of 80%. Politicians become a little self-congratulatory.

Yet… what has actually happened? The average waiting time has increased from 2 hours and 24 minutes to 3 hours and 36 minutes. 80% of patients are waiting longer than they did before.

And that is why—whatever the news tells you—we have no idea what happened to A&E waiting times last week. The average time could have doubled; it could have halved; it could have stayed precisely the same. We simply do not know.

In the game of poker that is the planning process for General Election TV debates, Cameron—the player with most to lose—is currently playing best. The broadcasters have played worst, totally fumbling their hand.

Cameron patently has the most to lose from taking part in the debates. Unlike Miliband and Clegg, he’s not all that unpopular as a leader. He has little to gain and much to lose from sharing a platform with Farage, and further legitimising UKIP’s candidacy.

Cameron’s demand for inclusion of the Green Party will not be met by the broadcasters. If it were, it would look like the participants had been chosen on Cameron’s recommendation alone—hardly a fair and impartial source—opening them to justifiable legal challenge from the other parties who want to take part.

So Cameron is faced with two possible outcomes: the broadcasters do not go ahead, in which case he comfortably sidesteps the problem; or—more likely in my view—the broadcasters go ahead and “empty chair” him.

In the latter case, all options remain open to Cameron. Changing his mind, if that’s the way the wind is blowing, is a one-day story at most. He could even duck the first debate, with Farage, on the grounds that he objects to UKIP’s inclusion without the Greens, take or leave the second (3-way) debate for much the same reason, and still face down Miliband in his preferred (and accepted) one-on-one format.

The debate including Farage will doubtless be a fiery occasion which will probably do damage on all fronts—but it’s likely to do more damage to those present than to an absent Cameron. Speeches criticising an absent leader don’t make for nearly such good TV as people yelling at each other. Clegg and Miliband’s commitments to “anyone, anytime” debates means that they can’t duck Farage; it might make sense for Cameron to let them demolish each other one-on-one in the second debate, too.

Cameron’s other advantage, which Miliband seems insistent on handing to him gift-wrapped, is that opponents are now calling for Cameron to debate in airtime they could be using to build a message or attack Cameron’s record. The media’s own obsession with the debates will likely trap them in this neutralised position until there is movement—which, clearly, Cameron will prefer to leave until the last moment. Cameron calculates—I guess accurately—that his apparent prevarication over taking part in TV debates damages him less than full-frontal attacks from his opponents.

The broadcasters bungled this process by announcing a plan rather than debates. The announcement of a plan implied room for negotiation and manoeuvre. Had they had the common sense to announce the invitees, the format, and the dates, making them fixed events to which leaders were invited, the landscape would now look very different—and I’d wager that all four leaders would be signed up.

The spanner in Cameron’s works could come from the “digital debate” proposed by The Guardian, The Telegraph and YouTube, and confirmed last week to include Cameron’s five preferred participants. Yet, despite being proposed a consortium which buys ink by the barrel, nobody seems to have noticed. If the two papers were to announce a date and invitation list on their front pages, along with assurance that they would “empty chair” those who didn’t turn up, all of those invited might find it difficult to graciously decline… and even more so if they could get a broadcaster to commit to covering (but, to ease the legal challenge, not producing) the event.

Unless the digital debate consortium make a move, it seems unlikely that anything will move in this story for a few weeks at least… but it will be fascinating to see how it plays out.

A number of politicians have recently made absurd statements about the role of the market and profit in healthcare, and specifically in the NHS. In political terms, the two worst culprits are the Labour Party and the National Health Action Party.

When the Labour Party left office in 2010, data1 showed that roughly 5% of NHS procedures were carried out in the private sector. Under the current Government, as of the most recent set of statistics, this is roughly 6%. It’s just worth bearing those proportions in mind whenever you hear Labour pontificate on the role of the private sector in the NHS. But I digress.

And for how much longer, in this the century of the ageing society, will we allow a care system in England to be run as a race to the bottom, making profits off the backs of our most vulnerable?

I’ll answer that question in a moment. But to illustrate that Burnham is not alone, let us turn to the National Health Action Party.

You may not have heard of the National Health Action Party: it is a well-meaning but misguided Party whose platform—to defend and improve the NHS—is as vague as it is logically flawed. Dr Richard Taylor, co-leader of the party, was previously an MP; he signed an Early Day Motion in support of homeopathy, and praised the use of acupuncture and reflexology in cancer treatment. To date, the party has contested and lost nine elections2 with their best result being a 9.9% share of the vote for a single council seat in Liverpool. Again, I digress.

This perfectly illustrates the difference between the private sector, which seeks profits, and public NHS Trusts … This shows exactly why the market has no place in healthcare.

So, you ask me, what’s wrong with those quotes? They seem like perfectly sensible sentiments to me!

Both of these quotes are simply nonsense. Neither the Labour Party nor the National Health Action Party are campaigning for the removal of profits and the market from the NHS—and nor is anyone else.

Any modern business, be it a hospital or fishmonger, is reliant on suppliers who will draw a profit. The NHS doesn’t manufacture its own light bulbs and baths, nor generate it’s own electricity,3 so people will draw profit from supplying them.

Alright, you might be saying, but that’s not really medicine, is it?

But of course, profits are made on medicine too. Sure, the NHS could manufacture all the medicines it needs—it already manufactures some.4 But many medications are under patent. Are NHS patients to be prevented from accessing patented drugs? Of course not: so companies will draw a profit. And the more sick people there are, the bigger the profit there is to draw.

OK, you say, but medicines are a special case.

Except they’re not. Almost every product used to deliver healthcare—from syringes to catheters to implants to surgical tools—will generate a profit, as it is almost all bought in from commercial manufacturers.

Come now, you say, supplies are a red herring. I’m interested in healthcare—a human caring for another human. There’s no profit to be made there!

Oh, but there is. Management of human resources is a tricky business. Often, Trusts will hire in external experts to help with training, planning or management, many of whom will work for consultancies which make a tidy profit.

Everyone knows human resources officers aren’t human, you intone—though I couldn’t possibly comment, I’m talking about a nurse looking after a patient at the bedside. Where’s the profit in that?

The scenario you describe is just dripping with profit—from the agency that recruited the nurse, to the profit on the manufacture of his uniform, to the cut of his pay which goes to the nursing agency he’s working for, to the cut of his car parking fee which is given to the private company managing the facility.

Ugh. You do go on a bit. What’s your point?

Suggesting that the NHS be removed from the commercial market and freed from the pursuit of profit is nonsense. Of course, the internal market in which NHS providers compete with one another could be reformed or removed, but the NHS is involved in a wider external market which is here to stay. The NHS is one of the country’s biggest purchases of goods and services, and each supplier will be doing the best they can to—effectively—profit from the sick.

Even if, for the sake of a thought experiment, we say that the NHS could be isolated totally from the battle for private profit, the end result in terms of the health service alone might not be that different: there would be continual pressure to reduce costs to the taxpayer, which is effectively the same financial pressure as increasing profits to shareholders.

The true argument is about the extent of involvement of the private sector.

Consider privately-employed doctors. Would we trust doctors to the same extent if we knew their interests balanced our interests with profit potential? This isn’t something we have to treat as a thought experiment: most GPs are small businesses and work on exactly this principal with little discernable effect on levels of trust. But, again, it feels icky.

Consider private sector management of whole NHS hospitals. This might look like a step too far: it takes a layer of previously publicly-funded management, who perhaps tried to balance the drive for profits with the best interests of patients, and moves them to the profit-hungry private sector. Yet, the management would always be accountable to commissioners, who would be looking out for the patients: so does it really matter? Perhaps not from the conceptual standpoint—but I’ll admit that it makes me more than a bit uncomfortable. And while a sample size of 1 makes for a poor trial, the fact that the first hospital so-run has become the first hospital to be rated as “inadequate” on patient care does not feel reassuring.

Consider public health campaigns teaming up with well-known brands. Is it okay if public healthcare money inflates Aardman Animations’s bottom line, if using Aardman characters is a good way to get health messages to children? I’m not sure: evidence about cost-effectiveness could sway me one way or the other.

Wouldn’t it be wonderful if we could have a debate on these issues that’s based in the real world, rather than the five-word soundbite world? Wouldn’t it be great if politicians would describe the extent of private involvement in the NHS that they believe to be appropriate, and we could then vote for the Party whose ideas most closely align with our own? Wouldn’t it be peachy if our politicians would stop patronising us all and treat us like adults?

As I said in my last post, the current model of delivery for the NHS is unsustainable. This is a problem that needs statesmanship, cross-party exploration, and—most importantly—tackling by adults.

Hospital Episode Statistics: the set of data that describes what happens in hospitals across the NHS in England. They’re not perfect by any means, and lag quite a way behind real time, but they’re the best we’ve got. ↩

The Eastleigh by-election, the London region in the European Parliament election, and seven local election seats. ↩

Actually, I have worked in a hospital that generated a lot of its own heat and power. They had pages and pages of information about it on the hospital intranet. As a junior doctor, I never got time to read it. ↩

The NHS manufacturers relatively tiny amounts of “special order” medication that isn’t available commercially. One of the units that does this work is based here in Newcastle, a stone’s throw from the site where William Owen first produced Glucozade as a special pharmaceutical product to aid recovery from common illnesses some 88 years ago. It was later sold to Beecham’s, renamed Lucozade, and is now everywhere, despite the fact that—to this blogger at least—it tastes vile. ↩

We’re 120 days from the UK General Election, and I’m already truly fed up with hearing absurd nonsense about NHS spending from politicians of all colours.

Society is ageing. There are 3 people of working age for every person of pensionable age in the UK.1 A little over two-thirds of working age people work, so there are, roughly, 2 working people for every person of pensionable age in the UK. By 2050—within my working lifetime—this ratio will approach or exceed 1:1.

Mean health spending per annum for a person of pensionable age is currently circa £5,000. That’s exclusively health spending; it doesn’t include social care costs, pensions,2 or anything else the Government spends to support the elderly. That £5,000 estimate is rising fast, and will continue to do so.

As the proportion of the population which is of pensionable age increases, and the costs per person of pensionable age increase, this model quickly becomes unsustainable. You reach a point, within decades, when the total tax burden becomes untenable. And before anyone says “but what about corporate taxes?”: these are, of course, paid by people, be they customers, workers or shareholders (which are mostly ordinary people via pension holdings).

Of course, it’s not all about the elderly—the young are getting sicker for longer too. As one of many examples: it’s been postulated that fully 10% of the current NHS budget is spent on diabetes-related care, and the prevalence of diabetes is rising by the month.

I believe passionately in the provision of healthcare free at the point of use. But I also believe that our current model for delivering this is broken. I don’t know how to fix it. This is where I’d like politicians to put forward bold and coherent visions of alternative ways of making this work.

What do we get instead? Monkeys arguing over peanuts. Even the National Health Action Party, whose raison d’étre should be to put this on the agenda, fail to articulate anything resembling an alternative.

Over the course of her term in office, Margaret Thatcher increased NHS spending by an average of 3% a year above inflation. These years are recalled as some of the darkest in the history of the NHS due to the perception of cuts—cuts which were, in reality, simply a level of investment which did not keep up with the rise in demand. The current budget of the NHS in England is £100m:1 a 3% per year above-inflation rise is £16bn extra funding per year by 2020.

Over the course of the next five years, the NHS estimates a £30bn per year budgetary shortfall if funding rises only in line with inflation.

Consider those two figures. £16bn per year on a Thatcherite scale of investment, £30bn per year needed according to the NHS itself. How do our political parties compare?

The Conservative Party claimed to be increasing the budget by £2bn in 2015/16 as a “down-payment” on £8bn per year future investment. However, it emerged that only £1.3bn of this was actually new money, and was for the whole of the UK, with Scotland and Wales taking £300m between them. So it’s a £1bn increase. Whether or not the rest of the £8bn will be made from smoke and mirrors—it’s way below what’s needed.

Labour want to invest an extra £2.5bn per year, which—depending on the announcement—they want to spend on one of myriad things, with seemingly no understanding that money can only be spent once. Not to mention that it’s far, far below the level of investment required to maintain the NHS in any case.

The Lib Dems have the most generous offer: £8bn per year. Half of what Thatcher would invest, a quarter of what’s needed. They expect NHS ‘efficiency savings’ to make up the shortfall. Where do they think the NHS is “wasting” £22bn at the moment? Perhaps I’ve too simplistic a mind, but it’s hard to see how a reduction in spending of £22bn isn’t a “cut”.

All three parties appear to have reached the same conclusion as me: it is unfeasible to continue to fund the NHS under the current model. Yet instead of tackling this head on, they are arguing over whose inadequate increase is biggest. Each party is complicit in maintaining a veil over the true scale of the problem, and bereft of anything approaching a plan to address it.

I appreciate that saying the current model of delivery for the NHS is unsustainable is a great way to lose an election. It’s a problem that needs statesmanship. It’s a problem that needs cross-party exploration. It’s a problem that needs tackling by adults.

The figures used in this post are intentionally rough and ready. They’re based on national statistics, but aren’t exact for a whole variety of reasons to do with stuff like rounding and comparability. I promise it doesn’t matter – the thrust is the same even if the figures are a bit out. ↩

Talking of pensions, the entire £100bn budget of the NHS—for people of all ages—is currently matched almost pound-for-pound in state pensions. This surely cannot be sustainable. ↩

19th November is International Men’s Day. The politics of International Men’s Day are often portrayed as complex, and many people seem to be of the opinion that it’s little more than a “me too” event to match International Women’s Day, or – at worst – some sort of anti-feminist fest.

But, for a moment, put the baggage to one side. It isn’t reasonable to argue that either men’s or women’s issues are more important – both are humanity’s issues, after all. But perhaps this is a good day to reflect on some of the challenges which are, in today’s society, more greatly burdensome for men than for women – just as we do the converse on International Women’s Day.

In that spirit, and without further comment, allow me to share ten statistics on which we can all reflect today.

A man ends his own life every two hours in the UK; three-quarters of those who kill themselves are men.

Men are 35% more likely to die of cancer than women – and if diagnosed with a non-gender-specific cancer, are 67% more likely to die from it.

90% of homeless people in the UK are men.

95% of the UK prison population is male.

Girls consistently outperform boys in education, and young men are 25% less likely than young women to get into university in the UK.

Young men are more than twice as likely as young women to be unemployed in the UK.

Men account for 96% of work-related deaths in the UK.

In England and Wales, men are twice as likely as women to be victims of violent crime, and twice as likely to be murdered.

In the UK, 40% of victims of reported domestic violence are men, yet there are few services and little funding to support male victims. As a result, male victims are substantially less likely to access professional support.

The BMA is asking members to sign a petition asking Government to repeal the Health and Social Care Act 2012. The leadership’s rationale is that the Act requires providers to compete, while the BMA believes that “collaboration and not competition is more likely to allow a greater integration of community and hospital services”.

I could not agree more: collaboration is more clearly in the interests of individual patients than competition, and collaboration seems at odds with competition. Yet I don’t think the BMA’s position should be to call solely for repeal of the Act: after all, the Act is not solely about competition. The legislation brought about many changes, some of which are working well.

For example, we are beginning to see the value of a new local authority perspective on influencing the wider determinants of health, as shown by the exemplary nominees for NICE’s local government public health award. This sort of progress can be found in many Local Authorities across England. To campaign for repeal of the Act is to surround this progress with a fog of uncertainty: repeal would reject this progress outright and move staff back into PCTs.

The Act limits the Secretary of State’s powers to intervene in the day-to-day running of the NHS. While the success of this has been questionable at best, we are beginning to see push-back against Government diktat. No one, except perhaps Lansley and Hunt, would argue that the NHS benefits from the Health Secretary holding operational control; yet repeal would reintroduce this.

The Act confers new responsibilities on NICE to support evidence-based social care. The Act provides the first (baby) steps towards regulation of healthcare support workers. The Act gives an unprecedented level of legislative support to research in the NHS. These may be small considerations in comparison to the problems of the Act, but outright repeal would (if I may mix metaphors) cast the baby and the bathwater both into uncertain territory.

How quickly the BMA seems to have forgotten the pain inflicted on our profession through restructure, job uncertainty, and redundancy. Excellent professionals left medicine — and especially public health — to pursue other careers, while others lived for years with the stress of the uncertainty of their positions. For the profession’s trade union to argue for yet another overnight reorganisation “so big, it can be seen from space” seems utterly perverse. Perhaps this is why, despite the BMA’s repeated urging, fewer than 4,000 people have signed the petition. Even if every signatory were a BMA member, this would represent less than 3% of the membership.

Repeal represents only a return to the past. It behoves professionals to put forward an alternative vision. For example, politicians refuse to discuss the threat to universal healthcare of having fewer taxpayers per patient as a result of an ageing population; yet the BMA is uniquely placed to devise a considered, collective, professional vision of the future of the NHS. To campaign only for repeal of what exists, and allow the next government propose and introduce yet another short-term model, seems to me to be a sure route to unhappiness.

The BMA should not call for repeal of the Act: this is opposition without a position. The BMA should identify the most insidious parts of the Act, and work tirelessly to scrap or rework them. But, more importantly, the BMA should thoughtfully advocate for the future health of the nation, not for a return to the systems of the past.

Ukip’s increasing popularity has generated acres of news coverage in the past few months. I thought I’d use this 2D post to pick two of the more thoughtful articles about Ukip’s leader.

Writing in Prospect, the magazine for which he’s associate editor, Edward Docx describes Farage’s “relentless charm” in an article with several arresting revelations. Perhaps the most intriguing, if not the most insightful, is that “close up, he smells of tobacco, offset with a liberal application of aftershave”. I found it not a little strange how much that added to Docx’s characterisation of the man. Perhaps the scent of all party leaders should become a regular feature of all political reporting.

Docx mentions Farage’s deft handling of a lack of policy detail, but in The Telegraph, Allister Heath goes a little further in taking Farage to task on the lack of coherent policy: he claims that “there are huge black holes at the heart of Ukip’s proposals”.

While these are two rather different articles in terms of tone, form and content, they do identify much the same traits in Farage, at least from the grand political point of view. Despite this, they come to utterly different conclusions: Heath argues that Ukip essentially doesn’t “stand up to detailed scrutiny”, while Docx argues that Farage can “make politics feel personally relevant again” and “show our parliament a way to recover its dignity”.

Both arguments are well worth reading.

2D posts appear on alternate Wednesdays. For 2D, I pick two interesting articles that look at an issue from two different – though not necessarily opposing – perspectives. I hope you enjoy them! The photo at the top of this post was posted to Flickr by the Euro Realist Newsletter and has been modified and used under Creative Commons Licence.

Nick Robinson’s Live from Downing Street is a thoroughly enjoyable romp through the history of the relationship between politicians and the media, from the very beginnings of Parliament to the present day. It’s part historical and part autobiographical, with the latter part in particular including lots of amusing anecdotes about Robinson’s time as a political journalist. Some of these genuinely made me laugh out loud. It also has a lengthy “last word”, in which Robinson muses on the future of political journalism, and the opportunities and threats offered by introducing to the UK biased broadcasting in the mould of Fox News.

He has an easy writing style making this an easy relaxed read. He sometimes has a slightly peculiar reliance on turns of phrase which fail to accurately communicate what he means to say: for example, there’s a passage where he introduces Gordon Brown’s disastrous flirtations with YouTube by saying that politicians have always been keen to embrace technology to communicate their message – something which he’s spent most of the first two-thirds of the book disproving.

He gives a very eloquent account of the effect of the plurality of media in the broadest sense meaning that people surround themselves with messages that support their world viewpoint, and the effect this in turn has on perceptions of bias at the BBC. This is something I’ve been banging on about on Twitter for ages, in a far less coherent manner, and it was interesting to see that the same thoughts have occurred to that organisation’s Political Editor. He also gives an interesting discussion of the nature of bias and impartiality, which I very much enjoyed.

There isn’t an awful lot of new stuff in this book. I think many people who follow politics in detail are probably aware of the history of the BBC and the historic developments in the relationship between journalists and the press. But Robinson presents all of this with such a clear narrative and in such a clear way that I still found myself very engaged with the content even when he was describing events I knew well.

The lengthy discussion of recent events and media figures – phone hacking being perhaps the most notable example – will probably make this book date quite quickly. Indeed, the mentions of Leveson “whose report has not been published at the time of writing” already make it feel a little behind the times, particularly since Leveson’s report covers much of the same ground discussed by Robinson.

This is a thoroughly enjoyable personal history of journalism, written by the then BBC Political Editor, and former editor of the Independent, Andrew Marr.

My Trade certainly delivers on its promise to provide ”A Short History of British Journalism”, but rather than delivering a dry journalistic history, Marr injects copious amounts of humour and panache. He provides many personal anecdotes – some longer and more developed than others, but all entertaining – and passes judgement on developments in the media world, rather than merely reporting their occurence. The personal touch makes the copy much more engaging, and prevents it descending into a super-extended newspaper feature, like so many other books by journalists.

Anybody interested in British journalism would be well advised to read a copy of this book. It provides much background on how newspapers are put together, and how this has changed over the years. It even provides some history on the rivalries between newspapers, looking at (as an example) how The Mirror’s sales declined at the hands of The Sun, and how Marr’s own Independent set out to be different from everyone else, but ended up being much the same.

This is not intended to be – and nor is it – a detailed history of the development of the British media. Instead, it’s an enjoyable romp through the subject, stopping off at points of interest – particularly recent ones, and many of which you’d have thought he may have liked to avoid. He goes into some detail about Hutton and the problems of modern journalism, making convincing arguments for his point of view – which is, in part, critical of his BBC paymaster. It’s very clear from his writing that he’s experienced as a journalist, not just because he lists his many and varied jobs, but also because of the detailed insight he is able to deliver, and the apparent wisdom of some of his comments.

Certainly, this is a very easy-going enjoyable read, from a political editor who comes across as an affable kind of chap, and a book which I must highly recommended.

I am not an MP for any reason other than because God wants me to be. I constantly try to do what Jesus would do.

So said Nadine Dorries in 2007. Obviously, Jesus has now recommended that Dorries abandons her constituents and takes a month off her regular job (while retaining a full £65,738 salary) to earn about £40,000 appearing on a tacky reality television show. God certainly works in mysterious ways!

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